Differences in National Diabetes Treatment Patterns and Trends between Older and Younger Adults

Abstract

BACKGROUND/OBJECTIVES: The treatment of type 2 diabetes in older adults requires special considerations including avoidance of hypoglycemia, yet variation in diabetes treatment with aging is not well understood. In this study, we compared nationally representative diabetes treatment patterns and trends between older adults (≥65 y) and younger adults (30–64 y). DESIGN: Repeated cross-sectional physician surveys from 2006 to 2015. SETTING: The National Ambulatory Medical Care Survey, an annual probability sample of visits to office-based US physicians. PARTICIPANTS: Adults with type 2 diabetes using one or more diabetes medications. MEASUREMENTS: Proportions of visits in which patients treated with each diabetes medication class were compared between older and younger adults in 2-year intervals. RESULTS: From 2006 to 2015, the average number of yearly visits for older and younger adults was 25.4 million and 24.2 million, respectively. In 2014–2015, visits for older compared with younger adults involved less use of metformin (56.0% vs 70.0%; p < .001) and glucagon-like peptide 1 receptor agonists (2.9% vs 6.2%; p = .004), and more use of long-acting insulin (30.2% vs 22.4%; p = .017); other classes were used similarly. During the study period, long-acting insulin use increased markedly in older adults, particularly between 2010 and 2015 where it rose from 12.5% to 30.2% of visits (P-trend <.001). In younger adult visits, long-acting insulin use increased modestly (17.2% to 22.4%) and at a slower rate compared with older adult visits (p < .001). CONCLUSION: The ambulatory treatment of type 2 diabetes differs between older and younger adults, with the treatment of older adults characterized by low use of newer diabetes medications and a greater and rapidly increasing use of long-acting insulin. These findings call for further research clarifying the comparative effectiveness and safety of newer diabetes medications and long-acting insulin to optimize diabetes care for older patients.

Hospital utilization for hypoglycemia among patients with type 2 diabetes using pooled data from six health systems

“…Consistent with other studies, we found that insulin use substantially increased over time suggesting that there may be protective factors countering this such as more effective diabetes treatment and hypoglycemia prevention strategies; further study is needed to clarify this. [41][42][43] We found substantially different rates of hypoglycemia hospital utilization among patient subgroups with known clinical hypoglycemia risk factors. Notably, insulin users had approximately 10-fold higher rates than those using diabetes medications with a low risk for hypoglycemia, and approximately fivefold higher rates than users of insulin secretagogues.…”

“…Despite temporal changes in the landscape of diabetes treatment, we found that rates of hospital utilization for hypoglycemia decreased slightly from 2009 to 2014, and were stable from 2016 to 2019. [41][42][43] It is possible that temporal trends in hypoglycemia were driven by differences in the study population, however the stability of the demographic and clinical characteristics of the cohort makes this unlikely. Consistent with other studies, we found that insulin use substantially increased over time suggesting that there may be protective factors countering this such as more effective diabetes treatment and hypoglycemia prevention strategies; further study is needed to clarify this.…”

“…44 Given that younger adults with type 2 diabetes have lower insulin use than other age groups, it is possible that younger adults face unique challenges related to their diabetes treatment that cause them to be at a higher risk for hypoglycemia, such as inconsistent access to care or adherence to diabetes medications. 41 More research is needed to understand hypoglycemia risk in younger adults and develop prevention strategies targeted to this age group. We found that patients in other age categories had lower odds of hypoglycemia hospital utilization, which is in contrast to prior studies which have found the highest rates of hypoglycemia among those aged 75 years and older.…”

The metabolic syndrome, thiazolidinediones, and implications for intersection of chronic and inflammatory disease

“…However long-term treatment of patients with type 2 diabetes often still requires the introduction of exogenous insulin to provide the best control of plasma glucose levels, once the initial treatment paradigms have failed. Moreover, in recent years, in spite of the availability of new agents, optimal control glycemia has not improved [ 16 ]. Some have argued for a broader use of pioglitazone because of its potential to prevent the loss of pancreatic β cell function and in particular, its efficacy in reducing cardiovascular disease, which remains the major cause of morbidity and mortality in both diabetic and prediabetic patients [ 17 , 18 ].…”

High Concurrent Use of Sulfonylureas and Antimicrobials With Drug Interactions Causing Hypoglycemia

“…6 Although use of sulfonylureas has been decreasing over the past decade, they remain the second most common oral diabetes medication class after metformin, used in nearly one third of ambulatory visits for patients with type 2 diabetes in the United States. 15,16 Sulfonylureas have drug-drug interactions with a number of antimicrobials causing a substantially higher risk of hypoglycemia when used together. [17][18][19][20][21] The fluoroquinolones ciprofloxacin, levofloxacin, and moxifloxacin have been associated with both hyperglycemia and hypoglycemia by altering pancreatic β-cell signaling.…”